Health Care / Medical Management
Resume:
EDUCATION
**** *** – Leadership, Capella University, Minneapolis, Minnesota
**** ** – Health Studies, Community Health, Texas Womans’ University, Denton, Texas
**** *** – Health Administration, Baylor University, Waco, Texas
1986 BSN – Nursing, George Mason University, Fairfax, Virginia
EXPERIENCE
Vibra Hospital of Sacramento, Folsom, California January 2014 to current
A for-profit, privately-owned Long Term Acute Care Hospital, Vibra Health Care, LLC.
Chief Clinical Officer/Chief Nursing Officer
Responsibilities: Oversight and accountability for all clinical operations of a 58 bed full-service specialty hospital with a 6 bed ICU, Medical-Surgical unit, Telemetry and a 2 room OR inclusive of PACU. Primary duties included providing management and direction for nursing, respiratory therapy, dietary, laboratory, blood bank, radiology, pharmacy, perioperative services, employee health, staff development, infection control, workman’s compensation and staffing coordination. Reported to CEO. Direct reports over 175 hospital staff.
Accomplishments:
• Following change in hospital ownership, facilitated team building, staff development and organizational activities to successfully build trust, recruit qualified staff and transition to new corporate culture, ensuring safe patient care and engaged employees.
• Successfully responded to California Department of Health (CDPH) licensure survey to increase beds from 39 to 58 leading the clinical team in a safe transition to provide care for the additional patients.
• Identifying a throughput deficiency from ICU to Medical-Surgical Unit, proposed, developed and implemented Progressive Care Bed policy resulting in improved patient flow and physician satisfaction
• Nursing Department:
o Facilitated Nursing staff development and implementation of a shared governance model which resulted in increased staff engagement.
o Improved nursing staff’s critical thinking abilities by providing ongoing hands-on educational support of resource nurses for bedside staff.
o Developed an ICU RN clinical training pathway augmented with simulation, a series of on-line Critical Care Orientation courses, preceptors and a Critical Care RN trainer to grow internal and strengthen current ICU RNs. Program was sourced using existing resources making program budget neutral.
• Restructured the Dietary Department to become patient-centered - resulting in improved food quality, reduction in labor costs and increased staff morale. A kitchen staff competence program was developed and a menu program was instituted linking menus to ordering.
• Realigned Respiratory Services resulting in better integration with clinical team, improved patient outcomes, increased wean rates and decreased wean days. No ventilator associated events for over one year.
• Laboratory services successfully passed CLIA survey with minimal findings.
Solara Hospital, McAllen/Edinburg, Texas August 2011 to November 2013
Two hospitals, for-profit, corporate-owned Long Term Acute Care Hospitals, Cornerstone Healthcare Group.
Chief Clinical Officer/Chief Nursing Officer
Responsibilities: Overall accountability for leadership and direction of all clinical departments including nursing, wound care, respiratory, and rehabilitation services of two hospitals totaling 78 beds providing care for 6 bed ICU, HOU, Telemetry and Medical-Surgical units. Hospital specialties included wound care, ventilator support, supportive rehabilitation, hemodialysis, and extended acute care greater than 25 days to patients older than 18 years old with multiple co-morbities. Reported directly to the Chief Executive Officer and assumed responsibilities for CEO in his absence. Provided oversight of 200 direct reports.
Accomplishments:
• Successfully responded to biannual CMS survey, invalid EMTALA complaint, and passed CLIA survey
• Received Lean Training and became facility leader for Lean Program, facilitating teams to establish wound care debridement program, improve call bell responsiveness, establish standard work for Case Management, instituted standardized clinician-physician rounding, instituted Huddle Boards to improve communication throughout facility.
• Created an ongoing ACLS training program with in-house trainers resulting in an all ACLS certified licensed staff and the capability for ongoing just-in-time training response to cardiac emergencies. Initiated increased Mock Code Blue and Rapid Response Drills.
• Nursing:
o Established shared governance for nursing staff to include the Nurse Staffing Committee and Nursing Peer Review resulting in improved nursing staff engagement, professional growth and retention. Staff development and succession planning incorporated in shared governance to ensure seamless turnover upon occurrence.
o Improved staff morale, retention, and recruitment as demonstrated by turnover rate less than 1% and contract labor of zero within 6 months, reducing staffing costs by $720k annually.
o Received Cornerstone Award for Most Improved Nursing Costs 2013
o Maintained staffing budget within established criteria for HPPD and nursing acuity.
• Implemented IHI bundles for CAUTI, CLABSI, and VAE, resulting in a sustained rate reduction below national benchmarks for over a year.
• Established a fully functioning Rehab department resulting improving patient and physician satisfaction
Conroe Regional Medical Center, Conroe, Texas April 2009 to June 2011
A 350-bed acute-care for profit community hospital, owned by HCA, Joint Commission Accredited, Certified Primary Stroke Center, Level III Trauma Center, and an Accredited Chest Pain Center
Director of Quality, Risk Management, and Medical Staff Services
Responsibilities: Accountability and coordination of all activities, reporting requirements and committees for the Quality, Risk Management and Medical Staff services. Committees coordinated with the provision of appropriate data included all the Medical Staff Departmental Meetings, Medical Executive Committee, Medical Staff Peer Review, Quality Council, Patient Safety, Performance Improvement Teams, and other ad hoc. Activities encompassed Core Measure and other data abstraction, analysis and management, CMS reporting, regulatory and accreditation requirement activities, risk management, complaint and grievance management, patient safety, physician relations, OPPE, FPPE, meaningful use roll out and credentialing and privileging for 400 active physicians with multiple specialties. Reported to the Chief Nursing Officer with oversight of 10 FTEs.
Accomplishments:
• Quality/Risk Management
o Streamlined Core Measure abstraction process to provide service-line support, which resulted in outcome measures above the 90th percentile for eight out of nine quarters. Consistent performance resulted in receipt of the Texas Healthcare Quality Improvement Award of Excellence 2009
o Successfully responded to the tri-annual Joint Commission survey, HCA Quality Review Survey (QRS), three annual Leapfrog Surveys, and three Texas Department of Health Services/CMS visits.
o Facilitated successful Joint Commission Disease Specific Care Advanced Stroke Center survey with no RFIs.
o Developed, implemented, and evaluated annual Quality, PI, and Risk Management Plans.
o Provided reports using data originating from internal and external databases such as Society for Thoracic Surgery (STS) and American College of Cardiology (ACC) to display results and analysis via dashboards and appropriate graphs.
o Successfully prepared and completed Phase 1 roll out of Meaningful Use initiative.
o Significantly reduced Fall Rate by initiating organizational rounding initiative
o Accountable for coordinating responses to all complaints and grievances while working closely with HCA legal team to mitigate risk, and, if necessary, respond to lawsuits and citations from CMS.
o Utilized Failure Mode and Effect Analysis (FMEA) and Root Cause Analysis (RCA) for facilitation of performance improvement and Risk Management activities.
o Standardized response and analysis of variances and close calls. Coordinated actions to recognize, manage, and respond to identified adverse trends, Serious Preventable Adverse Events (SPAE), and Sentinel Events.
o Successfully reported to the Joint Commission Sentinel Event occurrences and subsequent RCAs.
• Medical Staff Services
o Collaborated with HCA’s Central Processing Center (CPC) to transition centralization of all provider credentialing applications electronically and off-site to a centralized verification office (CVO)
o Ensured timely updates to Medical Staff By-laws.
o Initiated FPPE/OPPE and vendor screening programs.
o Directed coordination of all Medical Staff Committees including Peer Review, Credentials, and Medical Executive Committee.
University of Texas M.D. Anderson Cancer Center; Houston, Texas April 2005 to June 2009
Internationally recognized for excellence and ranked #1 by US News and World Report for cancer care, MD Anderson is a 600-bed not- for- profit research facility and academic medical center that provides inpatient care and close to one million ambulatory visits per year.
Director – Patient Safety & Accreditation (3/07-3/09)
Responsibilities: Coordinated all quality improvement activities for the facility to include accreditation, patient safety, clinical effectiveness, policy development and monitoring, regulatory compliance, and incident reporting. Reported to the Vice President for the Office of Performance Improvement and provided direct supervision of 16 FTEs.
Accomplishments:
• Successfully coordinated and led TJC survey, resulting in very successful survey of only 5 RFIs
• Maintained institutional readiness for TJC survey through use of tracers, collaboration with clinical and administrative leaders, ongoing self-assessment using the Periodic Performance Review (PPR), targeted education, and policy review and update.
• Redesigned management, review, and reporting of adverse events. Partnered with Information Technology department to update safety reporting system.
• Facilitated Root Cause Analyses (RCA), Failure Mode and Effect Analysis (FMEA), and other team meetings as indicated.
• Coordinated Patient Safety, Quality Council, and Ongoing TJC Readiness meetings to include presentations, agenda preparation, and arrangement for pertinent speakers. Instrumental in redesign of standing monthly Clinical Manager’s Forum, a monthly educational assembly created to disseminate information to all clinical staff. Created new working group for TJC Chapter Leaders and National Patient Safety Goal workgroup.
• Accountable for creating, implementing, and maintaining all budgetary activities of $1.6M for department, to include contracting functions for patient satisfaction and comparative database reporting – Thomson-Reuters’ and ORYX.
Senior Clinical Quality Improvement Analyst (4/05–2/07)
Provided interdepartmental support and committee guidance concerning Quality Improvement activities.
• Teamed with Medical Director of Critical Care, Nursing Director of Critical Care, and Pharmacy to standardize medication transcription and diluents volumes.
• Reviewed procedure incident reports, investigated any reports with harm, and performed rapid Root Cause Analysis on incidents requiring further action.
• Facilitated Glucose Management study in ICU. Designed survey and analyzed results for Glucose Management Study. Integrated evidenced-based training into development of policies for glucose management protocols.
• Led Saving 100,000 Lives Ventilator Associated Pneumonia team, which was recognized and requested to become a mentor group for the Institute for Healthcare Improvement.
• Partnered with Critical Care Quality Improvement group in the development of Leadership Walk rounds, Best Practice Committee, Adverse Events tracking and evaluation.
Consultant – self-employment April 1999 to April 2004
Consulted for defense contracting companies to provide functional analysis and clinical expertise for Department of Defense (DoD) Health Affairs information systems
Valytics, Vienna, Virginia (4/2003 to 3/2004)
A data management company providing testing and evaluation services to the Military Health Services.
Consultant – Functional Analyst
Responsibilities: Provided functional analysis and clinical expertise throughout the development, test, and evaluation cycle for information systems in the Department of Defense Health Affairs.
Accomplishments:
• Performed system change verification for the Central Credentials and Quality Assurance System (CCQAS) used to credential and privilege military physicians and other clinicians.
• Developed and executed the System Integration Test (SIT) Plan to test the system that was used for determining and tracking military medicine’s human resource management requirement, otherwise called the Defense Manpower and Human Resource System (DMHRSi).
Strategic Solutions, Inc., Washington, DC (4/1999-4/2001)
A company providing consulting services on information systems to the military health systems
Consultant - Project Manager
Responsibilities: Recognized as system expert; provided expertise and functional support for the US Navy on the Workload Management System for Nurses (WMSN), a Department of Defense system that projected nurse staffing and patient care requirements based upon patient acuity.
Accomplishments:
• Performed WMSN system analysis and functional review identifying shortcomings and areas for improvement and produced a poster-board presentation diagraming the system analysis and data quality which was presented at the Maryland Institute for Nursing Informatics and AMSUS conference.
Northrop-Grumman/Logicon, Falls Church, Virginia December 1996 to March 1999
A large defense contractor providing support to military health systems.
Functional Analyst
Provided clinical expertise in the integration and management of Department of Defense information systems.
• Coordinated integration and implementation of a clinical information system in the National Capitol Area’s medical treatment facilities.
• Educated and provided hands-on training for new electronic medical record for the National Capitol Area’s medical treatment facilities.
• Coordinated system change proposals and ran Configuration Control Board for the Department of Defense’s Composite Health Care System.
U.S. Navy July 1986 to December 1996
Navy Nurse Corps Officer – Active Duty
National Naval Medical Center, Bethesda, Maryland (6/93-12/96)
Department Head, Utilization Management (1/96–12/96)
Developed and implemented utilization management plan, direct supervisor of 6 utilization management nurses and liaison to utilization management physician.
Nurse Management Analyst (6/94–12/95)
Perform projects identified by Chief Nursing Officer.
• Managed and analyzed staffing statistics for 17 nursing units, to include educational support.
• Performed technical review, coordinated startup activities, and monitored contractor performance for contracts totaling $5.6M annually.
• Facilitated business process re-engineering team, redesigning third-party insurance collection processes to collect an additional $2M for FY96.
Administrative Residency (6/93–6/94)
Integrate theoretical concepts learned in didactic program into health care setting; completed feasibility study and plan for 23-bed LDRP, implemented in Fall 1996.
AMEDD, Ft. Sam Houston, Texas 6/92–6/93
Army-Baylor program full-time graduate student
Naval Hospital, Naples, Italy 7/89 to 6/92
Nursing Unit Manager - NSY/NICU (11/89 – 6/92)
Managed clinical activities of an isolated, overseas Level I/II/III Newborn Nursery. Maximized budget, equipment procurement, and advanced training and preceptor program to improve care capabilities of neonates up to Level III neonates. Developed and monitored annual quality assurance plan. Implemented self-scheduling. Reported to Assistant CNO. Managed and supervised 15 FTE professional and paraprofessional nursing staff.
Staff Nurse – Multidisciplinary Unit (7/89 – 10/89)
Provided nursing care for a clinically diverse mix of patients on a 28-bed, general med/surg unit providing medical-surgical, telemetry, pediatric, psychiatric, orthopedic and critical care.
Naval Hospital; Camp Pendleton, California - 10/86 to 6/89
Staff Nurse
o ICU (2/87–6/89)
o Medical-Surgical Unit (10/86–2/87)
LICENSURE/CERTIFICATIONS/FELLOWSHIPS
• California Nursing License # 95027728
• Advanced Cardiac Life Support (ACLS), 9/2013
• Certified Professional in Health Care Quality (CPHQ), 12/2005
• Baylor University Administrative Residency – National Naval Medical Center 1993-1994
PROFESSIONAL DEVELOPMENT
• U. T. M.D. Anderson Cancer Center’s Administrative Leadership Program (ALP) Leadership 2009
• Joint Commission Hospital Accreditation Essentials 2007
• U. T. M.D. Anderson Cancer Center’s Clinical Effectiveness & Safety Course 2007
• Evidence-based Training Course sponsored by University of Texas M.D. Anderson Cancer Center 2008
PROFESSIONAL MEMBERSHIPS
• American Organization of Nurse Executives
• American Association of Critical Care Nurses
• American College of Healthcare Executives
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